Minimally Invasive Aortobiilliofemoral Endarterectomy for Aortoiliac Occlusive Disease Is a Compelling Alternative to Bypass.

INTRODUCTION:: Aortobifemoral bypass is a time-honored, durable surgery allowing restoration of lower extremity blood. However, the potential for significant complications exists, impacting mortality, morbidity, and quality of life. Minimally invasive aortobiiliofemoral endarterectomy offers an alternative to prosthetic bypass and its associated complications. Here, we present a case series using remote endarterectomy for aortoiliac occlusive disease. METHODS:: Nine patients with aortoiliac occlusive disease were treated at a single institution, by a single surgeon, with direct and remote endarterectomy combination. Standard femoral access approach was used. A limited longitudinal distal aorta arteriotomy into the right common iliac artery to the hypogastric bifurcation was made. Then, an open thromboendarterectomy was performed. Circumferential common femoral endarterectomies were performed bilaterally and the plaque transected, allowing manually controlled Vollmar ring passage proximally to the iliac bifurcation on the right and the aortic bifurcation on the left. Aortoiliac arteriotomy was closed, followed by the femoral arteriotomies. Morbidity, secondary interventions, recurrent stenosis (adjacent segment velocity ratios ≥2), ankle-brachial index (ABI), and patency rates were tracked postoperatively for 6 years. Kaplan-Meier life-table analysis was used to determine patency rates per the criteria of SVS and ISCS. RESULTS:: The average age was 59.1 years (54-87 years), and 88% were male. Comorbidities included hypertension (75%), former/current smokers (100%), and prior PAD surgical intervention (38%). Revascularization of 100% was achieved, with average ABI improving from 0.42 preoperatively to 0.92 postoperatively (0.91 at 8-month follow-up). Six-year patency rate was 100% without reintervention. Incidence of myocardial infarction, stroke, death, amputation, intestinal ischemia, sexual dysfunction, and aneurysmal degeneration was zero after 6 years of follow-up. CONCLUSION:: Minimally invasive aortobiiliofemoral endarterectomy is a viable alternative to aortobifemoral bypass for the treatment of aortoiliac occlusive disease, allowing reestablishment of normal anatomic anatomy while avoiding the use of prosthetic material. Patency rates in this series was 100% at 6 years, with minimal postoperative complications or morbidity.

The Use of Branched Endografts for the Aortic Arch in the Endovascular Era.

The endovascular realm has steadily increased its footing in the treatment of the aorta and all of its territories since the foundational case in 1990 by Parodi. The aortic arch, however, continues to be one of the last bastions for treatment via open surgery, which remains the gold standard. Significant comorbidity and prior cardiac surgery prevent open surgery from being the only preferred option, allowing novel endovascular procedures to be considered. Since 1999, more advanced endovascular systems have been created by companies such as Cook Medical, Bolton Medical, Medtronic, Endospan, Gore Medical, and, recently, Kawasumi. The unique shape and angulation of the aortic arch often require the use of custom-made grafts, though arch reconstruction may also include in situ or back-table physician alterations to off-the-shelf devices. The goal of branched endografts is to exclude the aneurysm, while maintaining flow to supra-aortic trunk vessels. Technical success and device durability are limited by the physical constraints of the aortic arch, though greater experience may yield better patient outcomes. Typically, the initial stent-graft (SG) is introduced and deployed into the arch first. Bridging SG are then inserted via axillary or carotid access. Most often, the bridging SG extends from the innominate branch to the distal innominate, and from the left carotid branch to the left common carotid. The major concern is that manipulation of catheters and wires, both within the carotid arteries and aortic arch, create the potential for emboli leading to stroke and paraplegia. The development of endovascular-only techniques for aortic arch pathology will only increase with the aging population of the United States and associated accumulation of comorbidities, making open surgery too grave of a risk.

Hybrid Repair Techniques for Complex Aneurysms and Dissections Involving the Aortic Arch and Thoracic Aorta.

Aortic aneurysms involving the ascending aorta, aortic arch, and descending thoracic aorta have been a challenging entity to surgically treat for over 60 years. Despite the mortality of the disease, early open surgical procedures also had significant morbidity and mortality. The inherent risk in treating multiple anatomic segments simultaneously led to the innovation of the staged elephant trunk (ET) approach by Borst in 1983. To avoid the thoracotomy and associated complications related to the second stage of the procedure, an endovascular completion paradigm was begun by Volodos in 1991. This theoretical hybrid technique combinined shorter and less elaborate open supra-aortic trunk debranching with less invasive endovascular exclusion and has grown since then in terms of different approaches and case volume. The rise of thoracic endovascular aortic repair (TEVAR) combined with debranching bypass has allowed certain lesions to be treated without a large scale intrathoracic open surgical procedure. The complexity and extensiveness of certain lesions, however, has necessitated a hybrid approach such as the frozen elephant trunk (FET) and the standard ET with second stage TEVAR. The former has been used to treat multifocal degenerative aneurysms, chronic dissections with aneurysm, and acute extensive dissections. After conventional proximal aortic replacement, a stent-graft (SG) is delivered antegrade through the transected arch where it is sutured proximally and then "frozen" distally via endovascular means. The FET has the advantage of avoiding a second stage, but potentially introduces a greater rate of spinal cord ischemia compared to the standard elephant trunk. Improvements on the FET procedure have included the development of more advanced hybrid SG such as the Vascutek® Thoraflex™ Hybrid graft (Vascutek Ltd, Scotland, UK), which consists of a distal en,dograft sealed to a proximal four-branched Vascutek Gelweave™ Vascutek Ltd, Scotland, UK) and incorporated sewing collar. While open surgery continues to be a component of complex aortic arch aneurysms, the development of hybrid devices that can bridge the gap between open and endovascular surgery will continue to flourish.

Recanalization of failed autogenous conduit utilizing laser revascularization.

The traditional approach for the treatment of restenosis of autogenous vein bypass has been revision of bypass with vein patch angioplasty, interposition jump graft, or thrombectomy procedures for those patients with extensive occlusive disease and limb-threatening ischemia. Endovascular intervention traditionally involves angioplasty of the graft; however, vessels with diffuse disease or extensive longitudinal lesions are generally difficult to revascularize utilizing this technique. Surgical revision of a threatened autogenous vein graft may carry a morbidity rate as high as 13.6%. We present a series of cases in which excimer laser atherectomy (LA) was used to recanalize an occluded autogenous saphenous vein bypass. Of the occluded vein bypasses failed angioplasty and were successfully atherectomized with LA measuring lengths of 35 and 30 cm, respectively. The infrainguinal has a 6-month follow-up, while the infragencular has a follow-up of 1 year, with resolution of presenting symptoms.

Combined laparoscopy and transabdominal endoscopy: Case report of dislodged oesophageal stent retrieval.

The patient is a 39-year-old male with a five-month history of progressive dysphagia and a 70 lb weight loss. On upper gastrointestinal (GI) endoscopy he was found to have a near-obstructing mass in the lower oesophagus that was proven by biopsy to be oesophageal adenocarcinoma. Stricture caused by the adenocarcinoma mass was stented with a Cook Evolution 12.5 cm / 24 Fr stent, which dislodged subsequently. We report the first case of a dislodged Cook Evolution 12.5 cm / 24 Fr oesophageal stent that was retrieved using combined laparoscopic and transabdominal endoscopy.

Novel endovascular techniques for repair of traumatic bilateral axillary artery disruption with long-term follow-up.

We describe a case of innovative endovascular techniques to repair traumatic bilateral axillary artery disruption. A 36-year-old male construction worker fell eight stories from a scaffold and sustained bilateral axillary artery injuries. The injuries between the brachial and axillary arteries were bridged using long bare self-expanding stents (Zilver). To the best of our knowledge, this is a novel case report from a level-one trauma center where endovascular techniques were employed to repair bilateral axillary arteries with long-term follow-up.